Provider Demographics
NPI:1346770872
Name:MOORE, MICAH ROBERT (DO)
Entity Type:Individual
Prefix:DR
First Name:MICAH
Middle Name:ROBERT
Last Name:MOORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1320 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-8016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901
Practice Address - Country:US
Practice Address - Phone:304-645-3220
Practice Address - Fax:304-647-1273
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3323208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice